FORM – I[See clause 9(2)]

APPLICATION FOR REGISTRATIONTo The Labour Officer (Social Security Scheme),……………..district.Registration No…………(to be filled in by the Registration Authority)1.Name of the worker : 2.Name of the Father/Husband : 3.Date of Birth :(enclose Xerox Copy of evidence Day Month Yearin proof duly attested by a Group A or Group B officer)*4.Marital Status (Whether married, unmarried, widow/widower) : 5.Religion Caste :

6.Permanent address : 7.Present address : 8.State whether self-employed or employed : 9.If employed, furnish the name and address of the established and also the Name and address of the employer contractor : 10.Nature of work : 11.Number of years engaged in the employment as on the date of application : 12.Particulars of the member of the family :

Sl. No Name Age Relationship Marital status (1) (2) (3) (4) (5)

13. (a) Whether the wife/husband is employed ? : (b) If so furnish details14. Nomination for receipts of Natural Death/Accidental Death Assistance :

i) Birth Certificate or (ii) School Certificate or (iii) Driving License or (iv) Ration Card or (v)Voter’s identity card or(vi) Certificate from Registered Medical Practitioner not below the rank of civil Surgeon of a Government Hospital in the prescribed format duly signed by the worker.

**Any false declaration / certification will entail legal action.

**Nominees shall be Dependant Family Members.

Signature/Thumb impression of the manual worker

AffixPassport SizePhotograph

OC BC MBC SC ST

Name and address * *of the nominee/nominees

Nominee’s Relationshipwith the worker

Age of thenominee

Percentage of amount to paid to each nominee

(1) (2) (3) (4)

DECLARATION BY THE APPLICANT***

In declare that I am not registered as a member in any other Manual workers welfare board or Boards constituted by the Government of Tamil Nadu or under any other Government scheme.

Signature or left hand thumb impression of the manual worker. (Left hand thumb impression to be attested by the Registration authority)

____________________________________________________________________________CERTIFICATE OF EMPLOYMENT***

Certified that the particulars furnished by Thiru/Thirumathi/Selvi……………………………regarding employment as a manual worker in the application for registration are true to the best of my knowledge and belief.Place:Date :

Signature and name of the person/ Officer issuing the certificate***Any false declaration/certification will entail legal action____________________________________________________________________________

VERIFICATION CERTIFICATE

After due verification it is certified that the application and the proof are found correct and recommended for registration.

Place:Date :

Village Administrative Officer/ Revenue Inspector(for Chennai district)

____________________________________________________________________________Office Note:-Application and proof verified. The recommendation of the ……………………is accepted and the applicant is registered as member of the Tamil Nadu………………………Welfare Board.Application for membership rejected(In case of rejection, reason should be clearly mentioned).

Labour Officer (Social Security Scheme) …………………….District____________________________________________________________________________

ACKNOWLEDGEMENT SLIPReceived from Selvi/Thiru/Tmt………………………….residing at …………………………application for registration as manual worker in the Tamil Nadu …………….Welfare Board.Office Seal: Labour Officer (Social Security Scheme)With date

Name: Designation :

______________________________________________________________________

FORM – II

[See Clause 9 (4)]

IDENTITY CARD

TAMIL NADU

………………………..

WELFARE

BOARD

LABOURSTATUTE

IDENTITY CARD

SCHEME ASSISTANCES OF THE BOARD

1. Accident Insurance Scheme Rs.

(a) Accidental Death 1,00,000/-

(b) Accidental Disability Based on Extent of Disability

(C) Artificial limbs and wheel chair

as per the norms and at the rates fixed by the Tamil Nadu Differently Abled Person Welfare Board

2. Natural Death Assistance 15,000/-

3. Funeral Expenses Assistance 2,000/-

4. Educational Assistance:-

(a) Girl Children studying 10th

1,000/-

(b) 10th

Passed 1,000/-

(c) Girl Children studying 11th

1,000/-

(d) Girl Children studying 12th

1,500/-

(e) 12th

Passed 1,500/-

(f) Regular Degree Course 1,500/-

with hostel facility 1,750/-

(g) Regular Post Graduate Course 4,000/-

with hostel facility 5,000/-

(h) Professional Degree Course 4,000/-

With Hostel Facility 6,000/-

(i) Professional PG Course 6,000/-

With Hostel Facility 8,000/-

(j) I.T.I. or Polytechnic 1,000/-

With Hostel Facility 1,200/-

5. Marriage Assistancefor men 3,000/-for women 5,000/-

6.

Maternity AssistanceMedical termination of pregnancy /miscarriage of Pregnancy

6,000/- 3,000/-

7. Reimbursement of Cost of Spectacles Upto 500/-8. Pension 1000/- per month

TAMIL NADU ………………………

WELFARE

BOARD

AffixPassport

SizePhotograph

Registration No. :

Date :

1. Name :

2. Father / Husband :

3. Date of Birth / Age :

4. Employment :

Registration should be renewed before ...................................................

5. Permanent Address :

6. Present Address :

7. Marital Status :

8. Details of Nominees :

9. Registration Number if

Member of Trade Union :

Signature of the Worker Signature of the OfficerLabour Officer

(Social Security Scheme)…………….District

Details of Scheme Assistance provided to the worker

Sl. No. Name of the Name of the File No. Amount Signature of

Assistance Person and Date distributed the Officer

provided

Renewal details

Date of Renewal Receipt No. and Next Renewal Signature of the

Date Date Renewing Officer

with seal

GENERAL INSTRUCTIONS

The Registering individual should have completed 18 years of age and below 60 years

of age.

No Registration / Renewal Fee. Registration should be renewed once in two years. In case of loss of Identity Card, Duplicate Identity Card may be collected from the

Labour Officer (Social Security Scheme) of the respective district by remitting Rs. 20/-

In case of change of Residence new address should be intimated to the Labour Officer

(Social Security Scheme).

After Marriage of the worker, application should be made to the Labour Officer (Social

Security Scheme) for change of nominee I the Original Registration Application Form.

In the event of death of the worker, the original identity card should be surrendered to

the Labour Officer (Social Security Scheme) along with the application for Natural

Death Assistance.

The Original identity card should be enclosed along with claim application each time

when the Assistance is sought for.

UZHAIPPOM

UYARVOM

G. 133, Chinthamani Co-operative Commercial Complex,

Anna Nagar East, Chennai – 600 102. Phone : 26631149,26631150

FORM – IV

[See Clause 11 (4)]

REGISTER OF MEMBERS

Sl. No. Name of the Name and Date of RegistrationManual address of the Registration Numberworker establishment

(in case of selfemployed

worker indicatethe same)

(1) (2) (3) (4) (5)

FORM – VI

[See Clause 17 (3) (a) ]

ACCIDENT INTIMATION FORM

To

The Labour Officer (Social Security Scheme),…………………………….District…………………………….

To

The Inspector / Sub-Inspector of Police,…………………………….…………………………….

Sir,

Thiru / Thirumathi/Selvi/Selvan ……………………………… son of / wife of /

daughter of ……………………………………………………..employed in the work

place……………………………………………………………. has suffered loss of limbs /

loss of eye-sight/total disablement/partial injury/death due to accident.

(Signature of the Employer)

Address:Date:

Signature of the Worker/Nominee/Representative of a Trade Union.

“FORM-VII[see clause 17(3)(b)]

APPLICATION FOR PAYMENT OF COMPENSATION FOR ACCIDENTAL DEATH/DISABILITY

ToThe Labour Officer (social Security Scheme),……………………………………district.

1.(a)Name of the registered manual worker : (b)Address(in full) (on the date of death/disability) : (c)Age :

(d)Registration number and date of initial registration :

(e)Renewal date : (f)Occupation

2.(a) Area : (b)Place :

(c)District :

3.(a)Name of the nominee : (b)Relationship with the deceased registered manual worker

(in the case of accidental death only) : (c)Age of the nominee :

4.Whether the claimant is the registered worker? himself(in the case of accidental disability)or the nominee of the registered manual worker

5.Date and time of accident

6.Place of accident : (a)at the work place (b)outside the work place

7.Whwther intimation regarding accident has been given : in Form VI as per clause 17(3)(a)?

8.Whether the accident resulted in death/ loss of limb/loss of eye sight/partial injury? :

9.In the case of accidental disability, a certificate : from a civil Surgeon of the Government Hospital indicating the percentage of disability due to accident with details should be obtained and enclosed in original.

10.(i)Date and time of death(in case of accidental death) : (ii)Attested copy of First information Report from

the Police station nearer to the place of accident to be closed : (iii)Post-Mortem Certificate and final Investigation Report should be sent in original :

(iv)Death Certificate(attested copy)should be enclosed :

Signature/Thumb impression of the

registered manual worker/ Nominee in case of death.

DECLARATION BY THE CLAIMANT***

I hereby declare that the particulars furnished above are correct and true to the best of my knowledge. In the event of any of the information given above is ultimately found to be false, I hereby agree to refund in full the amount received as assistance foraccidental death/disability. I also hereby declare that I have not received similar benefit by claim in any other Welfare Board or boards constituted by the Government of Tamil Nadu or under any other Government schemes.Place:Date :

Signature/Thumb impression of the registered manual worker/ Nominee in case of death.

**Any false declaration/certification will entail legal action.______________________________________________________________________

SANCTION

I hereby sanction after due to verification for the immediate payment of Rs………/-(Rupees………………………. only) towards accidental death/disability to Selvi/Thiru/Tmt……….nominee of the deceased worker/registered worker himself.

Office Seal: Labour Officer (Social Security Scheme) …………………..district.

Place: (Affix Rubber Stamp)Date :

______________________________________________________________________

“FORM-VIII[see clause 18(2))

APPLICATION FOR PENSION

ToThe Labour Officer (Social Security Scheme),……………………district.

1.Name of the Applicant :2.Address in full(to which pension is to be sent)(with PIN code) :3.Registration number and date :(original identity Card should be enclosed)

4.Age and date of completion of 60 years of age :5. Whether the registration has been renewed regularly without any default?If so, details may be furnished :

Sl.No.

Date of initial registration/ Subsequent renewal

Period of validity of registration/renewal

From To(1) (2) (3) (4)

6.Whether in receipt of any other pension? If so, furnish complete details :

Signature/Thumb impression of the registered Manual worker.

DECLARATION*

I hereby certify that the facts mentioned above are true to the best of my knowledge and information. I am not a registered manual worker of any other Board. If ultimately it is found that any of the information given by me is false, I agree to refund the entire amount received by me as pension besides any other action that may be deemed fir by the appropriate authorities.

I also hereby declare that I have not received similar benefits by claim in any other Welfare Board or Boards constituted by the Government of Tamil Nadu or under any other Government schemes.

Place:Date : Signature/Thumb impression of the registered Manual worker. Name: *Any false declaration/ Certification will entail legal action.______________________________________________________________________Note:1.Besides the photograph affixed above, another passport size Photograph should be enclosed with the application. 2.Incomplete application will not be considered.

Passport size photograph duly signed

SANCTION

I hereby sanction, after due verification, a monthly pension of Rs………../-(Rupees……………only) with effect from……………………………….The amount shall be sent by money order.

Place: Labour Officer (Social Security Scheme)Date: ………..district .

________________________________________________________________

ACKNOWLEDGEMENT SLIP

Received from Selvi/Thiru/Tmt………………………….(Address in full)………………………………………........(Registration no………………………………)application for sanction of pension.

Labour officer (Social Security Scheme) …………district with dateName:Designation:

Office Seal:

________________________________________________________________

“FORM VIII-A[see clause 18(2)]

APPLICATION FOR DISABILITY PENSIONToThe Labour Officer (Social Security Scheme),………………………..district.1.Name of the Applicant :2.Address in full(to which pension is to be sent)(with PIN code) :3.Registration number and date(Original identity card should be enclosed) :4.Age and date of completion of 60 years of age :5.Whether the registration manual worker of the Board regularly without any default? If so,Details may be furnished

:Sl.No.

Date of initial registration/ Subsequent renewal

Period of validity of registration/renewal

From To (1) (2) (3) (4)

6.Whether the applicant has become disabled due to sickness and incapacitated from normal work?(If so, a certificate by a Medical Officer not below the rank of Civil Surgeon of the Government Hospital under his name and seal should be enclosed in Original) :7.Whether in receipt of any other pension? If so, furnish complete details :

Signature/Thumb impression of the registered manual worker.

DECLARATION**

I hereby declare that the facts mentioned above are true to the best of my knowledge and information. I am not a registered worker of any other Board. If ultimately it is found that any of the information given by me is false, I agree to refund the entire amount received by me as disability pension besides any other action that may be deemed fir by the appropriate authorities.

I also hereby declare that I have not received similar benefits by claim in any other welfare Board or Boards constituted by the Government of Tamil Nadu or under any other Government Schemes.Place: Signature/Thumb impression of the Date: registered manual worker.

Name:**Any false declaration/certification will entail legal action.______________________________________________________________________Note:1.Besides the photograph affixed above another passport size Photograph should be enclosed with the application. 2.Incomplete applications will not be considered.

SANCTION

I hereby sanction after due verification a monthly pension of Rs……………./-(Rupees …………………………only) with effect from………………..The amount shall be sent by money order.

Office Seal:Place:Date: Labour Officer (Social Security Scheme)

…………..district______________________________________________________________________

ACKNOWLEDGEMENT SLIP

Received from Selvi/Thiru/Tmt…………………… (Address in full)…………………………………………………..(Registration No. ……………………..)application for sanction of disability pension.

Labour Officer (Social Security Scheme)………………district with dateName:

Office Seal: Designation:

“FORM-IX[See clause 19(2) and 20(2)]

APPLICATION FOR PAYMENT OF FUNERAL EXPENSES/NATURAL DEATH ASSISTANCE

ToThe Labour Officer (Social Security Scheme)……………………district.

1.Name of the deceased registered manual worker :2.Address in full(at the time of death) :3.Age(on the date of death) :4.Nature of work :

5.(a)Registration Number and date of initial registration (original Identity card should be enclosed). :

(b)Date of last renewal, indicating the period upto which renewed

6.(a)Place of death : (b)Date of death : (c)Cause of death(to be indicated clearly)

(Avoid indicating as ”Natural Death”) (Death Certificate in original shall be enclosed) :

7.(a)Name of the nominee : (b)Age on the nominee(in completed years) : (c)Address of the nominee in full indicating PIN Code : (d)Relationship of the nominee with the deceased

registered manual worker :

signature/Thumb impression of the nominee of the registered manual worker

DECLARATION OF THE NOMINEE*

I hereby declare that the particulars furnished above are correct and true to the best of my knowledge. In the event of any of the information given above is ultimately found to be false, I hereby agree to refund in full the amount received as assistance for death/funeral expenses of the deceased manual worker.

I also hereby declare that I have not received similar benefit by claim in any other welfare board or Boards constituted by the Government of Tamil Nadu or under any other Government schemes.

Place: Signature/Thumb impressionDate : of the nominee of the registered manual worker

*Any false declaration/Certification will entail legal action.

CERTIFICATE*

I hereby certify that the particulars furnished in the application are correct.Place:Date: Members,………….TamilNadu………………………………

Welfare Board/President/Secretary of the Registered TradeUnion of the Employment concerned/Assistant InspectorOf Labour concerned/Any other officer permitted to giveEmployment certificate.

*Any false declaration/certification will entail legal action

SANCTION

1.I hereby sanction, after due verification, a sum of Rs…………./-(Rupees………………………….only) as assistance to Thiru/tm,t/Selvi…………………..,nominee/ nominees, for the funeral of Thiru/Thirumathi/Selvi……………………………….A registered manual worker.

2.I hereby sanction, after due verification, a sum of Rs………………/-(Rupees………………………….only) as assistance to Thiru/Tmt/Selvi………………………,nominee/nominees, on the natural death of Thiru/Thirumathi/Selvi……………………………a registered manual worker.

Office Seal:Place: Labour Officer (Social Security Scheme)Date : ……………………………district.

ACKNOWLEDGEMENT SLIP

Received from Selvi/Thiru/Tmt………………………………………………………. .……………………………………………………………………………….claim application for sanction of Funeral/Natural death assistance in respect of deceased registered manual worker Selvi/Thiru/Tmt…………………………………(Registration No………………..)

Labour Officer (Social Security Scheme)…………district with dateName:

Office Seal: Designation:

“FORM-X[See Clause 21(3)]

APPLICATION FOR EDUCATION ASSISTANCE FOR PASS IN10TH STANDARD AND 12TH STANDARD EXAMINATION

ToThe Labour Officer (social Security Scheme)………………………district.

1.Name of the registered manual worker :2.(a)Registration Number and date of intial registration (original Identity card should be enclosed) : (b)Date of last renewal, indicating the period upto which renewed :3.Address(in full) with PIN Code :4.Details of family members of the registered

manual worker:- Sl.No

Name Relationship with the registered manual worker

Age

(1) (2) (3) (4)

5.Details of the son or daughter for whom educational assistance is sought for:-

Sl.No

Name(son/Daughter)

Date of Birth

Examinationpassed

Month and year of pass

Name of the School studied

(1) (2) (3) (4) (5) (6)

Note:-Xerox copy of the Mark Sheet in support of having passed the Examination dulyattested by a Group A or Group B Officer should be enclosed.

6.Number of children for whom the educational assistance has already been availed from the Board:-Sl.No

Name Son/Daughter Course for which assistance availed

Year of availingAssistance

Amount of assistance

(1) (2) (3) (4) (5) (6)

Signature/Thumb impression of the registered manual workerDECLARATION BY THE APPLICANT*

I hereby declare that the particulars furnished above are correct and true to the best of my knowledge. In the event of any of the information given above is ultimately found to be false, I hereby agree to refund in full the amount received as assistance. I further declare that I have not availed similar assistance from any other Welfare Board or Boards constituted by the Government of Tamil Nadu or under any other Government Schemes.Place:Date: Signature/Thumb impression of

the registered manual worker*Any false declaration /certification will entail legal action.

CERTIFICATE*

I hereby certify that the particulars furnished in the application are correct.

Place:Date: Members,………….Tamil Nadu………….

Welfare Board/President/Secretary of the Registered. Trade Union of the Employment concerned/Assistant Inspector ofLabour concerned/Any other Officer permitted to give employment certificate.

*Any false declaration/Certification will entail legal action.

SANCTION

I hereby sanction, after due verification a sum of Rs………../-(Rupees………………………..only) as educational assistance, in respect of *Selvan/*Selvi………………….*Son/*daughter of *Thiru/Tmt………………………….Registered manual worker (Registration No……………………….).

Office Seal:Place: Labour Officer(Social Security Scheme)…………..district.Date:

ACKNOWLEDGEMENT SLIP

Received from Thiru/Tmt/Selvi/………………….(Registration No…………)claim application for sanction of educational assistance.

Labour Officer (Social Security Scheme)…………….district with date

Office Seal: Name:Designation:

______________________________________________________________________

“FORM-XI[See Clause 21(3)]

APPLICATION FOR EDUCATIONAL ASSISTANCE FOR GIRL CHILDREN STUDYING IN 10TH STANDARD/12TH STANDARD

ToThe Labour Officer (social Security Scheme)………………………district.

1.Name of the registered manual worker :2.(a)Registration Number and date of intial registration (original Identity card should be enclosed) : (b)Date of last renewal, indicating the period upto which renewed :3.Address(in full) with PIN Code :4.Details of family members of the registered

manual worker:- Sl.No

Name Relationship with the registered manual worker

Age

(1) (2) (3) (4)

5.Details of the son or daughter for whom educational assistance is sought for:-

Sl.No

Name Date of Birth

Standard in which studying(Std.10th /11th

/12tth )

Year of study(indicate the academic year)

Name of the School with full address

(1) (2) (3) (4) (5) (6)

Note:- Certificate from the Head Master/Principal of the School to the effect that the daughter of the registered manual worker is studying the course, should be enclosed. 6.Number of children for whom the educational assistance has already been availed from the Board:-Sl.No

Name Son/Daughter Course for which assistance availed

Year of availingAssistance

Amount of assistance

(1) (2) (3) (4) (5) (6)

Signature/Thumb impression of the registered manual worker

DECLARATION BY THE APPLICANT*I hereby declare that the particulars furnished above are correct and true to the best of my

knowledge. In the event of any of the information given above is ultimately found to be false, I hereby agree to refund in full, the amount received as assistance.

I also hereby declare that I have not received similar benefits by claim from any other welfare Board or Boards constituted by the Government of Tamil Nadu or under any other Government Schemes.Place:Date : Signature/Thumb impression of the registered manual worker.*Any false declaration/certification will entail legal action.

CERTIFICATE*

I hereby certify that the particulars furnished in the application are correct.

Place:Date: Members,………….Tamil Nadu………….

Welfare Board/President/Secretary of the Regd. Trade Union of the Employment concerned/Assistant Inspector ofLabour concerned/Any other Officer permitted to give employment certificate.

*Any false declaration/Certification will entail legal action.

SANCTION

I hereby sanction, after due verification a sum of Rs………../-(Rupees………………………..only) as educational assistance, in respect of Selvi………………….daughter of Thiru/Tmt………………………….Registered manual worker (Registration No……………………….).

Office Seal:Place: Labour Officer(Social Security Scheme)…………..district.Date:

*Strikeout whichever is not applicable.

ACKNOWLEDGEMENT SLIP

Received from Thiru/Tmt………………….(Registration No…………)claim application for sanction of educational assistance.

Labour Officer (Social Security Scheme)…………….district with date

Office Seal: Name:Designation:

______________________________________________________________________

“FORM-XII[See Clause 21(3)]

APPLICATION FOR EDUCATION ASSISTANCE FOR HIGHER EDUCATIONToThe Labour Officer (social Security Scheme)………………………district.

1.Name of the registered manual worker :2.(a)Registration Number and date of intial registration (original Identity card should be enclosed) : (b)Date of last renewal, indicating the period upto which renewed :3.Address(in full) with PIN Code :4.Details of family members of the registered

manual worker:- Sl.No

Name Relationship with the registered manual worker

Age

(1) (2) (3) (4)

5.Details of the son or daughter for whom educational assistance is sought for:-

Sl.No

Name Date of Birth

Name of the course studying

Duration of the course

Name of the College/InstitutionWith address in full

(1) (2) (3) (4) (5) (6)

Note:- Certificate from the principal of the college/Educational institution to the effect that the son or daughter of the registered manual worker is studying the course indicating whether a day scholar or hosteller should be enclosed in original.

6.Number of children for whom the educational assistance has already been availed from the Board:-Sl.No

Name Son/Daughter Course for which assistance availed

Year of availingAssistance

Amount of assistance

(1) (2) (3) (4) (5) (6)

Signature/Thumb impression of the registered manual workerDECLARATION BY THE APPLICANT*

I hereby declare that the particulars furnished above are correct and true to the best of my knowledge. In the event of any of the information given above is ultimately found to be false, I hereby agree to refund in full, the amount received as assistance.

I also hereby declare that I have not received similar benefits by claim from any other welfare Board or Boards constituted by the Government of Tamil Nadu or under any other Government Schemes.Place:Date : Signature/Thumb impression of the registered manual worker.

*Any false declaration/certification will entail legal action.

CERTIFICATE*

I hereby certify that the particulars furnished in the application are correct.

Place:Date: Members,………….Tamil Nadu………….

Welfare Board/President/Secretary of the Registered. Trade Union of the Employment concerned/Assistant Inspector ofLabour concerned/Any other Officer permitted to give employment certificate.

*Any false declaration/Certification will entail legal action.

SANCTION

I hereby sanction, after due verification a sum of Rs………../-(Rupees………………………..only) as educational assistance, in respect of *Selvan/*Selvi………………….*Son/*daughter of *Thiru/Tmt………………………….Registered manual worker (Registration No……………………….).

Office Seal:Place: Labour Officer(Social Security Scheme)…………..district.Date:

ACKNOWLEDGEMENT SLIP

Received from Thiru/Tmt/Selvi/………………….(Registration No…………)claim application for sanction of educational assistance.

Labour Officer (Social Security Scheme)…………….district with date

Office Seal: Name:Designation:

______________________________________________________________________

“FORM-XIII[See clause 22(4)]

APPLICATION FOR PAYMENT OF MARRIAGE ASSISTANCE

ToThe Labour Officer (Social Security Scheme)………………………district.

1.Name of the registered manual worker : 2.Registration Number and Date of initial registration (Original identity card should be enclosed) : 3.Address in full with PIN Code : 4.(a)Particulars of the members of the family of the registered manual worker:

Sl.No Name Relationship Age Marital Status (1) (2) (3) (4) (5)

( b).(i)Name of the person for whose marriage the : assistance is sought for (ii)Relationship to the registered manual worker : (iii)age in completed years on the date of marriage : (c).Names of the couple(i)Bride : (ii)Groom : (d).Date and venue of the marriage (Marriage invitation to be enclosed in original) : (e).Has the marriage assistance been availed earlier from the Board? If so, furnish details :

Signature/Thumb impression of the registered manual worker.

DECLARATION BY THE APPLICANT*

I hereby declare that the particulars furnished above are correct and true to the best of my knowledge. In the event of any of the information given above is ultimately found to be false, I hereby agree to refund in full, the amount received as assistance for the marriage of self/daughter/son.

I also hereby declare that I have not received similar benefits by claim from any other welfare Board or Boards constituted by the Government of Tamil Nadu or under any other Government Schemes.Place:Date : Signature/Thumb impression of the registered manual worker.

*Any false declaration/certification will entail legal action.______________________________________________________________________

CERTIFICATE*

I hereby certify that the particulars furnished in the application are correct.

Place:Date: Members,………….Tamil Nadu………….

Welfare Board/President/Secretary of the Registered. Trade Union of the Employment concerned/Assistant Inspector ofLabour concerned/Any other Officer permitted to give employment certificate.

*Any false declaration/Certification will entail legal action.

SANCTION

I hereby sanction, after due verification a sum of Rs………../-(Rupees………………………..only) towards assistance of the son/daughter/self of Thiru/Tmt………………………….registered manual worker of the Board (Registration No……………………….).

Office Seal:Place: Labour Officer(Social Security Scheme)…………..district.Date:

ACKNOWLEDGEMENT SLIP

Received from Thiru/Tmt/Selvi/………………….(Registration No…………)claim application for sanction of marriage assistance.

Labour Officer (Social Security Scheme)…………….district with date

Office Seal: Name:Designation:

______________________________________________________________________

“FORM-XIV[See Clause 23(3)]

APPLICATION FOR PAYMENT OF MATERNITY ASSISTANCEFOR PREGNANCY OR MISCARRIAGE OR TERMINATION OF PREGNANCY BY A

REGISTERED FEMALE MANUAL WORKERToThe Labour Officer (Social Security Scheme)…………………….district

1.Name of the registered female manual worker : 2.(a)Registration Number and date of initial registration (Original Identity card should be enclosed) : (b)Date of last renewal indicating the period upto which renewed : 3.Address(in full)with PIN Code : 4.Particulars of surviving son/daughter of the registered female manual worker :

Sl. No.

Name Sex Date of Birth Age

(1) (2) (3) (4) (5)

5.Month of Pregnancy*on the date of claim application : *(Certificate from the civil assistant Surgeon of the Government Hospital in support of this should be enclosed in original) 6.Whether the claim is for pregnancy or miscarriage of pregnancy or termination of pregnancy?

If so details may be furnished.(Certificate from the Civil Assistant surgeon of the government Hospital To this effect should be obtained and sent in original) : 7.Whether the assistance has already been availed by the registered female manual worker? If so, details may be furnished :

Signature/Thumb impression of the registered manual worker.

DECLARATION BY THE APPLICANT* I hereby declare that the particulars furnished above are correct and true to the best of my knowledge. In the event of any of the information given above is ultimately found to be false, I hereby agree to refund in full, the amount received as assistance. I also hereby declare that I have not received similar benefits by claim in any other welfare Board or Boards constituted by the Government of Tamil Nadu or under any other Government schemes.Place:Date :Signature/thumb impression of the

registered female manual worker.*Any false declaration/certification will entail legal action.

Note:- (i) The Birth Certificate from the Register of Births of the area concerned should obtained and sent in original for release of the assistance after the date of delivery.

(ii) In the event of untoward demise of the registered female worker after the 7th month of pregnancy either before delivery or three months after delivery, the fact should be reported to the Medical Officer of Primary Health Centre concerned and for Chennai district to the Health officer concerned, immediately along with the Death Certificate in original, for sanction of Funeral Expenses(or)Natural death assistance as admissible under the scheme.______________________________________________________________________ CERTIFICATE* I hereby certify that the particulars furnished in the application from are correct.Place: Date : Members, ……………………Tamil Nadu ………………………………..Welfare Board/

President/Secretary of the Registered Trade Union of the Employment concerned/Assistant Inspector

of Labour concerned/Any other officer permitted to give employment certificate.

*Any false declaration/Certification will entail legal action.______________________________________________________________________

SANCTION

I hereby sanction, after due verification, for the payment of assistance of Rs………………./-(Rupees ……………………………………..only) to Tmt………………………registered female manual worker(Registration No…………)*at the time of seventh month of pregnancy/*on delivery of child/*for miscarriage of pregnancy/*termination of pregnancy(*Strike out whichever is not applicable).

Office Seal:Labour officer (Social Security Scheme)

…………….district.

ACKNOWLEDGEMENT SLIP

Received from Tmt……………………………………….registered female manual worker(Registration Number…………………..)claim application for sanction of maternity assistance for*pregnancy/*miscarriage of pregnancy/*termination of pregnancy in respect of the registered female manual worker.*Strikeout Whichever is not applicable

Labour Officer(Social Security Scheme)………………………..district

Name:

Office Seal: Designation:

“FORM-XV[See Clause 24(1)]

APPLICATION FOR REIMBURSEMENT OF COST ON PURCHASE OF SPECTACLES BY THE REGISTERED MANUAL WORKER

ToThe Labour Officer (Social Security Scheme)…………………….district

1.Name of the registered manual worker : 2.(a)Registration Number and date of initial registration (Original Identity card should be enclosed) : (b)Date of last renewal indicating the period upto which renewed : 3.Address(in full)with PIN Code : 4.Date of purdhase of spectacles and its actual cost : 5.Whether certificate issued by a registered Opthalmist is enclosed in original? : 6.Whether cash bill is enclosed in original? :

Signature/Thumb impression of the registered manual worker.

DECLARATION BY THE APPLICANT* I hereby declare that the particulars furnished above are correct and true to the best of my knowledge. In the event of any of the information given above is ultimately found to be false, I hereby agree to refund in full, the amount reimbursement towards purchase of spectacles for myself. I also hereby declare that I have not received similar benefits by claim in any other welfare Board or Boards constituted by the Government of Tamil Nadu or under any other Government schemes.Place:Date :

Signature/thumb impression of theregistered female manual worker.

*Any false declaration/certification will entail legal action. CERTIFICATE* I hereby certify that the particulars furnished in the application from are correct.Place: Date : Members, ……………………Tamil Nadu ………………………………..Welfare Board/

resident/Secretary of the Registered Trade Union of the Employment concerned/Assistant Inspector

of Labour concerned/Any other officer permitted to give employment certificate.

*Any false declaration/Certification will entail legal action.______________________________________________________________________

SANCTION

I hereby sanction, after due verification, the reimbursement of a sum of Rs………………./-(Rupees ……………………………………..only) to Selvi/Thiru/Tmt……………………… , towards the actual cost on purchase of spectacles for himself/herself.

Office Seal:Labour officer (Social Security Scheme)

…………….district.

ACKNOWLEDGEMENT SLIP

Received from Thiru/Tmt/Selvi……………………………………….registered manual worker(Registration Number…………………..)claim application for reimbursement of cost on purchase of spectacles for himself/herself.

Labour Officer(Social Security Scheme)………………………..district

Name:

Office Seal: Designation: